Provider Demographics
NPI:1447312475
Name:SIMONETTI, STEPHEN (DC)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:SIMONETTI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 149TH ST
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1641
Mailing Address - Country:US
Mailing Address - Phone:718-746-4777
Mailing Address - Fax:718-746-4738
Practice Address - Street 1:708 149TH ST
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-1641
Practice Address - Country:US
Practice Address - Phone:718-746-4777
Practice Address - Fax:718-746-4739
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXX003564-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05712GMedicare PIN